Patient Forms
Established Patients Access
Through our patient portal, you can request appointments, request medication refills, and print forms. Your request will be responded to within 24-48 hours, during normal business hours. If you do not receive confirmation of your request within 48 hours, please contact our office by phone.
- Patient Portal Appointment Request
- Patient Portal Medication Request
New Patient Information
We are excited to partner with you in your child’s health and look forward to providing compassionate, high-quality care. This section is designed to help you prepare for your first visit, ensuring a smooth and stress-free experience. Here, you’ll find important information on what to expect, necessary forms, and how to make the most of your child’s appointment.
Please note: At this time, Delaware Pediatrics is not accepting new Medicaid patients.
Adolescent Transfer Policy
Delaware Pediatrics accepts new patients up to 17 years of age for transfer into our practice. We will only accept transfer patients who are 17 years or older if they have a sibling under 17 who is also transferring to our practice.
If you have any questions or need more information about our transfer policy, please call our office at (716) 884-0230.
Forms Information
To view the forms listed below, you will need Adobe Reader. You may download Adobe Reader for free at www.adobe.com.
We recommend printing and filling out the forms below before your first appointment with our office. Please print and complete the Authorization of Release (Transfer in/Transfer out) form and return it to your previous doctor’s office. We do not request medical records on your behalf. It is your responsibility to ensure your child’s records are transferred to our office in a timely manner. If your records are not received prior to your scheduled NEW patient appointment, your appointment maybe rescheduled.
New Patient Forms
- New Patient Welcome Letter
- New Patient Demographics
- Vaccine Policy Statement
- Patient Responsibility Agreement
- Notice of Privacy Practices
- Patient-Centered Medical Home
- Transfer In Form
- Authorization for Medical Treatment of Minors